I just can’t give it up – addiction and multiple needs

WY-FI supports people who are not engaging effectively with services and are experiencing entrenched needs in at least three of the following HARM areas:

Homelessness

Addiction

Reoffending

Mental ill health

WY-FI does not deliver services but works with existing local services to co-ordinate and work together effectively to fully meet individual needs in a person-centred and co-ordinated way via a Multi-Agency Review Board.

WY-FI Beneficiaries

WY-FI has been working with beneficiaries for just over two years and in that time we have started to build up a picture of what experiences make up life for an individual who has multiple needs. The challenge for service providers and WY-FI Navigators is that there is an interdependence between the four HARM (Homelessness, Addiction, Re-offending and Mental ill health) themes which result in either exclusion from, or ineffective engagement with, services.

Addiction

In previous WY-FI Strategic Stakeholder Group meetings we have looked at homelessness, re-offending and mental ill health – but noted the impact that addiction has on all three. Addiction can be both a cause and a symptom of a chaotic or traumatic life and addressing addiction where it exists with other needs cannot be achieved in isolation.

The classification of addiction (or “problematic substance use”) is not always helpful as it covers a wide range of consequences and substances – drinking, opiates, prescription drugs, cannabis and new psychoactive substances. The outcomes data from general drugs services shows that there can be equally successful and unsuccessful treatment outcomes amongst the same cohort of drug users undergoing the same psycho-social and extended intervention treatment pathway. It appears that the motivations to start and stop using substances seem at least as important as the treatments on offer.

How does WY-FI make a difference?

WY-FI Navigators make a difference in two main ways, they practically support people to make and keep appointments with drug and alcohol services and they walk alongside the service user and help keep them motivated to make positive change in their lives. A sample of WY-FI beneficiaries completed an Insight Survey questionnaire which gave them the opportunity to explain what difference having a Navigator made. They said,

“I have an excellent and understanding Navigator”

“Staying away from drugs is easier with my Navigator”

“My Navigator gives me the support to move on”

Other results from the Insight Survey show the difference that having Navigator support makes to individual’s experience of services.

Navigators also have a crucial role to play, along with Multi-Agency Review Boards (MARBs) in drawing together packages of support for beneficiaries and obtaining flex from services. Often in the case of addiction, this includes allowing someone to be re-admitted to a service after an exclusion because of their use of substances – which is incompatible with other treatments or service provision because of behaviour whilst under the influence. People experiencing dual diagnosis tend to have much more access to addiction services than mental health services, certainly in the early stages of treatment.

Referrals

As you would expect, referrals to WY-FI of people with addictions come from a wide range of sources as a number of different agencies have a stake in the individual’s recovery. One of the most notable referrers to WY-FI are addiction services themselves (34% of WY-FI referrals) indicating that there is a proportion of their own clientele that they can’t engage with or are too chaotic or risky to work with, without a navigator.

Even so, not everyone who needs support, makes it to an addiction service. The proportions vary from district to district but there are typically between a third and a half of beneficiaries experiencing addiction who do not access addiction services. WY-FI looked at an area where there was a very low proportion of males experiencing addiction who had not received a service. Reasons for low levels of recorded engagement, even with navigator support, included:

Working with people who were acknowledged locally as never having, nor ever likely, to engage with addiction services

Individuals being recalled to prison prior to attending their first appointment

Individuals dying prior to attending their first appointment

Individuals not having attended their first appointment at the point of the data snapshot

abstinence-based recovery services – these are often peer-led and managed but often new to the partnerships delivering addiction services.

Certainly the re-configuration and re-commissioning of services offers opportunities to improve the services for beneficiaries. However, the process of procurement, commissioning and subsequent implementation seems to be reducing the capacity of services during the handover from one provider to another or as existing services are re-configured to achieve savings. Whilst services are receiving more and increasingly diverse referrals, clients seem to be directed towards narrower and more prescriptive treatment pathways.

What works for WY-FI beneficiaries?

WY-FI beneficiaries tend to be more complex and more chaotic or entrenched in their substance use than mainstream users of addiction services. A number of them will be mandated to use services as the result of a court order or condition of probation. Individuals with multiple needs want:

to feel safe about using services

to be listened to

to be respected by workers, and

to have a say in their treatment and support plans.

There was a strong message that people with multiple needs were “stuck” in substitution-based services and often couldn’t progress because they had been excluded because of their behaviour or because they had missed appointments. In some cases people didn’t get the support they needed after leaving prison quickly enough. There was a lot of support for abstinence-based recovery groups and the notion of “recovery” became a central tenet of WY-FI. Many experts by experience and beneficiaries value the abstinence support from people who have experienced problematic substance use themselves. This seems to work well with detox in the community, clinical detox and/or rehab. The ongoing support is critical and is often linked to support around other challenges in the lives of beneficiaries. There is also a recognition that recovery groups don’t work well for everyone – just like other treatments.

Drug related deaths

Recent media reports highlighting the increased death rate of drugs service users for example in the Guardian and BBC demonstrate the change in the demographic profile of drugs services’ clients. Reasons for the increased death rate include: increasing age of drug services’ clients (particularly opiate users) and the additional health problems attributed to their drug use or lifestyle since the 1980s and 1990s (the last “waves” of heroin epidemic in the UK).

Also on the increase are deaths from New Psychoactive Substances (what were “legal highs”) which in WY-FI’s experience tend to be more heavily used by younger and more chaotic beneficiaries. The reports point towards the personalisation of services and multi-agency work that addiction services could be a gateway to, if they were designed differently. These reports also illustrate some of our previous findings that there are possibly two distinct types of people experiencing multiple needs: older more entrenched beneficiaries who are more sceptical about the help offered by services and younger, more chaotic beneficiaries that services can’t maintain engagement with. This is an area which the WY-FI Research and Evaluation Team will explore further.

The figures

The WY-FI Research and Evaluation team have collated a powerpoint presentation to illustrate some of the points made in the above blog. Download the presentation

Case studies

Here we present two case studies showing the costed journeys of two WY-FI beneficiaries, both experiencing addiction but receiving very different treatment/care. The two cases presented show different aspects and outcomes of beneficiary experience of services. We don’t yet know if they are representative of a wider pattern.

The first beneficiary is on a substitution programme (methadone script) and is someone who is particularly high risk both as a victim and someone who presents as very chaotic. Drug use is for self-medication and there is the use of street drugs on top of erratic use of prescribed methadone. The use of street drugs has led to a series of physical health complications. The ongoing prescription of methadone does not appear to be associated with improvement in other aspects of the beneficiary’s life, which appears to be governed by a fragile psychological state which so far doesn’t seem to have been treated (or treatable).

The second beneficiary was cared for in a “wet house”. The beneficiary is a more entrenched drinker with a history of trouble with the police when “in drink”. The beneficiary spent a period in a “wet” hostel where he was able to drink moderate amounts and rarely to excess. There seems to have been a series of low level incidents which culminated in his discharge (eviction) from the hostel. However, the beneficiary has maintained navigator support and after a period of sofa-surfing and street-sleeping the beneficiary is now sustaining their own property and needing little WY-FI support. The beneficiary continues to drink, but in a much more managed way than previously. The beneficiary also reports that he can manage better around other people when he has taken drink and this has reduced his offending record.

Chaos and Outcomes Scores

The graphs show costs associated with each beneficiary’s journey as well as the number of hours support provided by WY-FI. Costs ‘above the line’ are for positive rehabilitative interventions. Negative costs ‘below the line’ include expenses to the public purse related to homelessness, addiction, re-offending and mental ill health.

Both graphs track each beneficiary’s Chaos Index Score and Homeless Outcomes Score. The Chaos Index Score (also known as NDTA score) is an assessment undertaken by a navigator to establish whether an individual will benefit from WY-FI support against a series of need criteria. This is repeated regularly to measure progress. The maximum Chaos Score possible is 48. The Homeless Outcomes Star Score is a self-assessment tool for beneficiaries to measure their distance travelled. The maximum score possible is 100. Where progress is positive, we would expect the Chaos score to decrease and the Outcomes score to increase.

The Housing Outcomes Star scores have steadily improved for the beneficiary being prescribed methadone but the Chaos scores, having initially improved, have worsened (but not as bad as initially) and have plateaued. As a result, the beneficiary’s offending behaviour has not reduced and nor has her drug misuse.

Conclusion

These case studies highlight the ongoing nature of addiction and recovery and the inter-relatedness with other issues – particularly how the beneficiary relates to others. Certainly, with the first beneficiary there is a strong sense that some form of confidence building and motivation is necessary to mitigate against the damaging cycle of vulnerability, addiction and psychological distress but possibly even more intensive and co-ordinated support is required to achieve that.

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